Implementation is the fourth stage in the Strategic Prevention Framework after assessment, capacity building and planning. Coalitions 'turn the corner' when they detail what needs to be done, figure out who does what, when and where and 'do the work.' Carrying out and documenting delivery of planned services, improving and sustaining characterize the implementation stage as coalition members’ step forward to carry out and oversee different parts of the coalition’s work.

Engaging members in ongoing quality improvement during implementation helps coordinate activities as well as create a shared responsibility for success. This guide describes a continuous quality improvement process for implementing evidence-based strategies and activities. It requires wide distribution of implementation plans, conducting the program, documenting variations from the plan, assessing progress toward goals and modifying program activities to better achieve intended outcomes.

During the implementation phase communities continue to reach out to all community sectors, particularly those most impacted by tobacco use. New stakeholders are recruited, oriented and involved in decision making. Everyone associated with conducting the program works to better understand unique features of the culture in which the activities are conducted.

How well the coalition plans for sustainability at this stage determines whether the initiative is a brief flash of light or whether it is an ongoing effort capable of achieving its long term goals. Sustainability requires creating a team and a plan dedicated to securing the resources to keep the coalition in the game after the initial funding.

It is not just “what you plan to do” but rather “how well you do what you planned to do” that creates meaningful change in communities.

Implement Comprehensive, Evidence-Based Programs

Multiple Program Goals and Population-Based Strategies

Implementing effective community tobacco prevention and control programs requires a comprehensive approach that addresses at least four program goals. [1] Major reductions in tobacco use have been achieved under the goals of:

Preventing youth from smoking

Helping current smokers quit

Protecting the public from secondhand smoke

Identifying and eliminating tobacco-related health disparities

Implementing comprehensive programs employs at least four population-based strategies that influence a large proportion of the population. [2,3] Population-based approaches include:

State and community interventions to influence organizations, systems and networks that encourage and support individual behavioral change consistent with tobacco-free norms. Many of these can be found in national registries of evidence-based programs.

Program policy and regulation such as policy analysis and education of decision makers and the public on the benefits of clean indoor air, tobacco excise taxes, product regulation, insurance coverage for tobacco use treatment and cessation programs and ingredient disclosure.

Surveillance and evaluation regularly monitor key measures over time to assess progress and inform program and policy development. Additional information on what to measure can be found in Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs[4]

Population-Based Strategies Change Social Environments

Numerous studies have shown that the most effective way to reduce tobacco use is to focus on implementing change in social environments. Social environments exist around individuals, at the community level and in the broader economic, cultural and political spheres. The most significant and sustained declines in tobacco use have been observed in areas where changes in social environments have been the focus of programs. Implementation of comprehensive tobacco programs encourages the use of social change strategies simultaneously in multiple environments.

Document What Is Done

At this stage the role of coalition members moves from planning to oversight, mutual accountability and monitoring. During the planning stage the coalition selected intervention strategies and programs demonstrated to be effective. They also developed detailed action or implementation plans around each goal. Evidence-based programs are only effective if they are fully implemented. Conducting activities described in the implementation plan needs to be paired with a thorough understanding of what happens when the intended program activities “meet the community.” Coalition members focus their attention on documenting how the program is actually implemented along with any changes that are made.

One way to monitor implementation is to create checklists or tables to describe the extent to which the program was carried out as planned. Record activities in the order in which they are completed along with any activities that were not done or did not work and new activities you created to take the place of those that did not work.

Behavioral Health Integrated Provider System

In addition to program implementation charts, each DSHS funded coalition enters performance data into the online Behavioral Health Integrated Provider System (BHIPS). This system captures selected demographic, service and participant data on all of its substance abuse prevention programs. Less detailed than program implementation documentation, it provides accountability on use of funding and facilitates the automatic submission of DSHS required data and automated billing system.

Written agreements made with community organizations to more effectively provide tobacco prevention, cessation and secondhand smoke strategies through community mobilization and empowerment

Process Evaluation for Continuous Quality Improvement

How well a program is delivered influences the ability of the coalition to achieve its goals. Process evaluation provides information to assist community coalition members get the most “mileage” out of their programs.

Process Evaluation

Process evaluation, sometimes called “implementation” evaluation, helps determine whether a program is being delivered as planned. A process evaluation might ask whether the number of people reached is more or less than expected, whether individuals reached are members of priority populations, and whether the program is being delivered according to the planned protocol. Process evaluation provides information to the coalition to improve program delivery as well as to stakeholders who want to know about the level and quality of program activity.

Improving the Way We Work

Aside from documenting what is actually” done”, process evaluations help staff and planners improve program delivery and enhance outcomes. When used for this purpose process evaluations become part of a continuous quality improvement cycle.

A continuous quality improvement cycle begins with 1) development of action plans describing the ideal conditions and activities to be conducted, by whom, for whom, with what, when and how. As 2) these activities unfold, coalition members 3) document the way in which these activities are actually conducted.

Several months into implementation, coalition members 4) assess progress toward short term goals and compare each action plan to documentation of what actually was done and then 5) revise their action plans to better align program activities with intended outcomes. If after 3- 6 months of implementation, the group is not seeing short term results it should make “mid course changes” in the way the program is delivered.

Facilitating Discussion of Mid-Course Changes

When delivering information on the progress of a coalition, frame the discussion in a manner that recognizes the work that has been done while at the same time maximizing future efforts to better reach coalition goals. By focusing on the positive and presenting the data as a “gift”, you convey optimism about the prospect of success as well as the need to make adjustments to the plan. The University of Kansas Community Tool Box provides online instruction on how to conduct discussions on modifying programs http://ctb.ku.edu/. Do the Work, Chapter 39, describes ways to engage stakeholders in review of data-based findings.[5]

The following questions can help guide a discussion on making mid-course changes to implementation plans.

How much progress are we seeing toward our short term and intermediate outcome objectives?

Which objectives are being met?

Which program components are working well?

Which program components are not showing progress?

For the outcome objectives that are not showing progress, was each program activity completed as planned? What deviations were made from the implementation plan?

Was the staff trained/ qualified to conduct the program?

How many people/organizations were exposed to each activity?

How many materials were distributed?

What were participants’ perceptions of each activity? Of the program?

What were the strengths of the way the program was implemented?

What were the barriers or challenges to implementation?

Were all resources needed for project activities readily available?

What was the nature of interactions between staff and participants?

Where do improvements need to be made? What about changing:

Materials or Messages?

Training?

Outreach?

Organization?

Duration or frequency of the activity?

Delivery method or location?

What needs to be done to more effectively implement key program components?

What changes need to be made in the program or in the way we deliver it to improve its acceptability by our community?

Increase Cultural Competency

Selecting evidence-based program strategies and activities capable of achieving the intended outcome is a critical step toward solving community problems. Fully implementing activities in a manner acceptable to the community is equally important.

Try to see the program through the eyes of the target group. Not all programs require adaptation. If the delivery method, channel, or message needs to be modified to increase acceptance by the target group then do so, but document what you have done.

Culturally Appropriate Strategies that “Fit” the Community

Consider community values and context when implementing evidence-based strategies. Seek the advice of key stakeholders before fully implementing any program.

Before attempting to implement an evidence-based program find out:

What are the unique characteristics of the people living in an area where the program will be offered?

How comfortable are they using services provided by the tobacco prevention & control coalition?

What are the unique characteristics of the population on which the evidence-based intervention was tested?

What type of change is the program intended to produce?

What is simple to use?

What is practical to use?

What changes need to be made in the program or delivery of the program to improve its acceptability in our community?

More detailed strategies for building culturally competent organizations and programs that “fit” a community can be found online through the University of Kansas Community Tool Box http://ctb.ku.edu/ Do the Work.5 Chapter 27 includes information and activities on building relationships with people from other cultures, multicultural collaboration, transforming conflicts in diverse communities and understanding culture, social organization and leadership to enhance community engagement. Chapter 19 provides more specific guidelines on how to adapt programs to the community.

How to Sustain the Work

It is never too early to think about how to broaden the coalition’s impact and continue its work after the initial funding period. Population-based strategies and changing policies, systems and environments take time…often years to complete. Since most coalitions are funded for relatively short time periods actions need to be taken early to leverage additional resources to allow it to achieve its goals. Coalitions should be working on securing the resources to sustain their work at least by the time they begin to implement program activities.

Start the Process – Set up a Sustainability Team

Recruit, orient and organize an action team specifically charged with defining what needs to be sustained to keep the program operational and then work to develop the necessary resources.

One of the first decisions the team will need to make is whether to pursue outside funding or whether current coalition members can identify resources within their organizations to sustain its work. Typically coalition members have decided to work together because the work is important to their constituents. If they support the goals and mission they may be likely to adopt the work of the coalition into their organizational structure. Investigate adoption of the coalition’s work by member agencies before pursuing the pathway to external funding.

Many resources exist in the community – a place to meet, an unused office space in a member’s office building, or an extra computer. Building partnerships and leveraging resources within the community can also achieve sustainability for long term reductions in tobacco use.

Define What Needs to be Sustained

What are the goals, strategies or activities that need to continue in the short term (next 6 – 12 months) as well as the next five years? Action plans in support of the coalition’s 3-5 year strategic plan serve as a framework for identifying resources needs. Typically they include physical facilities, personnel, funding and materials needed to conduct the activities to achieve its goals.

When defining what needs to be sustained, think beyond tobacco prevention and control programs. The systems change skills that the group uses to advance its cause are also important. If the coalition, for example, has been using the Strategic Prevention Framework to plan and conduct its tobacco prevention and control activities, plan to continue use of data-based public health practices in your list of resources that need to be sustained.

Create Case Statements

Spread the word that you are in need of support. Present your case to potential stakeholders as well as local foundation staff and members of the board of directors, service organizations and individuals with a vested interest in the problem. The Overview and Capacity Building guides in this series include suggestions for creating a written “pitch” or case statement to assist members in stating their case to potential supporters and funding agents. The pitch should include the group’s mission and goals as well as information on why potential supporters should be interested in reducing tobacco use.

Put the pitch in writing. The case for support can be as simple as a one-page letter or a more lengthy proposal that establishes why the coalition’s work is important to them, benefits of the work to the community and resources needed to achieve its goals.

Identify the Funding Strategy & Create An Action Plan

Before investing time developing additional financial resources, talk with other coalition members about adopting the program. Member organizations are already working with the coalition because the goals are either directly or tangentially consistent with their goals. Ask if their organizations would be interested in taking on the coalition’s work after the initial funding period. If so, what is the potential for creating a line item in their budget to pursue these goals? Another strategy is to invite several organizations to contribute resources to extend the coalition. If the decision is to pursue outside funding, start by creating an action plan.

Prepare List of Potential Funding Agents

If adoption or institutionalization within existing community organizations doesn’t look promising, investigate outside funding. Check the yellow pages in local telephone books under Foundations – educational and philanthropic for lists of groups that provide support to your community. The Directory of Texas Foundations is another good source for information on philanthropic organizations throughout the state.

The foundation directory is available from the Non Profit Resource Center of Texas by online subscription http://www.nprc.org/site/ as well as for purchase. The 27th Edition includes over 3300 private, community and public charities in Texas giving grants and support to nonprofits. It describes foundations by 1) grants, assets and grant distribution, 2) areas of interest, 3) city, foundation name, trustees and officers, and 4) type of support and giving interests of the top 100 foundations in major cities and regions of Texas.

Identify Relevant Requests for Proposals

Subscribe to online announcements of state wide public health funding and training opportunities such as Funding Alert http://webds.dshs.state.tx.us/fic/subscribe.htm or call (512) 458-7111 x 6483. The Funding Alert is published monthly through the Texas Department of State Health Services. While this service typically reports on public and private funding opportunities with statewide impact, it often solicits Requests for Proposals from individual communities.

Key internet sites in Texas that lend themselves to potential public funding agents include the Electronic State Business Daily http://esbd.cpa.state.tx.us and State of Texas eGrants http://www.texasonline.state.tx.us/tolapp/egrants/search.htm . The Electronic State Business Daily site includes requests for proposals and bids for all state agencies, colleges, universities and municipalities. The eGrants site was set up in 2007 and allows users to search for grants by keywords, agency, geographic area or eligibility category.

Explore Local Tobacco Settlement Funds

Disbursements from the Texas Tobacco Settlement continue to be made available to Texas hospital districts and political subdivisions. In 1996, Texas filed a federal lawsuit accusing the tobacco industry of violating conspiracy, racketeering, consumer protection, and other provisions of state and federal law. The state sought to recover billions of the tax dollars it had spent to treat tobacco-related illnesses.

In settling the lawsuit, the industry agreed to pay the state $15 billion over 25 years and to also pay about $2.3 billion through 2003 to Texas counties and hospital districts based on their provision of indigent health care. Use of this money is unrestricted although most of the money is going toward health care since hospital districts have received the largest share of payments.[6] A case for dedication of tobacco settlement funds to community tobacco prevention and control can be made based on the argument that, as long as tobacco use continues, communities will be faced with ongoing un-reimbursed tobacco-related health care costs.

Several Texas communities are leading the way in protecting their citizens and planning for sustainability using a combination of Texas Tobacco Settlement and community foundation funding. The Amarillo Hospital District is the first hospital district in the state to use its tobacco settlement funds for a comprehensive tobacco control program. This program has been in continuous operation since 2001. See http://www.tfreeamarillo.com El Paso, through the Paso del Norte Health Foundation created a Smoke Free Paso del Norte as one of its primary funding priorities. See http://www.pdnhf.org

A list of Texas Tobacco Settlement disbursements to local political subdivisions dating back to 2000 can be found online at http://www.dshs.state.tx.us/tobaccosettlement/pay2008.shtm The following chart illustrates the type of information available during 2008.[6]

Tobacco Settlement Payees by HOSPITAL DISTRICTS

2007 Un-reimbursed Health Care Expenditures*(to the nearest dollar)

2008 Distribution(to the nearest dollar)

Bexar County Hospital District

$ 185,585,914

$ 8,265,753

Ector County Hospital District

$ 25,951,188

$ 1,155,832

Lubbock County Hospital District

$ 15,460,667

$ 688, 598

Lynn County Hospital District

$ 709,153

$ 31,585

Midland County Hospital District

$ 13,447,380

$ 598,929

Tobacco Settlement Payees by COUNTY

2007 Un-reimbursed Health Care Expenditures*(to the nearest dollar)

2008 Distribution(to the nearest dollar)

Crosby County

$ 10,963

$489

Dickens County

$ 26,546

$ 1,182

Fort Bend County

$ 13,425,233

$ 597,942

Gaines County

$ 489,740

$ 21,812

Gregg County

$ 2,584,795

$ 115,123

Hale County

$ 1,221,043

$54,384

Hockley County

$ 944,565

$ 42,070

Smith County

$ 4,042,390

$ 180,043

* Tobacco-related health care costs are estimated to account for about 15% of all Medicaid expenditures [7]

Develop and Submit Funding Proposals

Each funding agent typically has a unique format and funding cycle. Create an action plan to describe what you need to do and who will do it. Take time to find out not only what the funding agency’s goals are but also who is on its board of directors and when they fund proposals. The University of Kansas Community Tool Box, Chapter 42, Getting Grants and Financial Resources, provides stepwise instructions for preparing proposals.[5]

For more information on building sustainability check out the Center for Substance Abuse Prevention’s website. The site also include PowerPoint presentations useful in orienting coalitions to ways to build sustainability. See http://prevention.samhsa.gov/sustainability/default.aspx

Tools

Sample Action Plan

Goal: Prevent Youth Tobacco Use

Objective: By August 2009, increase by 25% middle & high school youth awareness of tobacco industry advertising

Monitor and record the way the program/evidence-based strategies are implemented in the community

Assume that plans are always implemented the way they are described in “the plan”

Set up action teams to secure people and resources to carry out coalition’s work after the initial funding period

Assume that “someone” will automatically provide the resources to continue the initiative

Review differences between the implementation plan and the way it is actually delivered. Identify and implement changes to improve program delivery

Assume that no further action is needed once the program has been implemented and documented

References

Department of Health & Human Services (US), Reducing tobacco use: a report of the surgeon general. Atlanta: Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2000. Also available from URL http://www.cdc.gov/tobacco/sgr/sgr_2000/FullReport.pdf .

Department of Health & Human Services (US), Tobacco control activities in the United States, 1994-1999; report to congress. Atlanta: Centers for Disease Control and Prevention; 2000.

University of Kansas, The community toolkit: Sustaining the work and Enhancing culturally competency Accessed online training on 8/18/08 at http://ctb.ku.edu/dothework/ .

Texas Department of State Health Services, List of political subdivisions that received a payment in the 2008 distribution of tobacco settlement proceeds, Accessed online 5/27/08 at http://www.dshs.state.tx.us/tobaccosettlement/default.shtm .

Centers for Disease Control and Prevention. Smoking-attributable mortality, morbidity, and economic costs (SAMMEC): Adult SAMMEC and Maternal and Child Health (MCH) SAMMEC Software. Available at http://www.cdc.gov/tobacco/sammec